Maternal Health History Form

US Zika Pregnancy Registry

OMB: 0920-1143

IC ID: 222494

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Maternal Health History Form
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction NA Maternal Health History Form ATT_A_USZPR_Maternal_Health-History_Form_Revised 21SEP2016.docx NA Yes Yes Fillable Fileable

Health Public Health Monitoring

Epidemiologic Studies and Surveillance of Disease Problems; 09-20-0136  57 FR 62812

1,100 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,000 0 0 0 0 11,000
Annual IC Time Burden (Hours) 5,500 0 0 0 0 5,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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